Failure to Investigate and Address Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that allegations of verbal and physical abuse of one resident by another were thoroughly investigated and that appropriate corrective actions were taken. Multiple documented incidents showed a pattern of verbal and physical aggression by one resident towards another, including yelling, threats, and physical altercations such as slapping and punching. Despite staff witnessing these events and documenting them in behavior notes, there was no evidence that the facility initiated or conducted a thorough investigation into these incidents. The clinical records and staff interviews revealed that the resident who was the victim had severe cognitive impairment, as indicated by a BIMS score of 00, and a history of dementia and muscle weakness. The alleged perpetrator also had dementia, along with major depressive disorder, anxiety disorder, and schizoaffective disorder, and exhibited repeated aggressive behaviors, particularly when the victim was near another resident. Staff documented multiple episodes where the aggressor yelled at, threatened, and physically confronted the victim, sometimes in the presence of other residents and staff. Family members of the victim also reported noticing physical signs of harm, such as a bruise on the victim's face, after being informed by staff of an altercation. Despite these repeated incidents and staff awareness, the facility did not document any initiation of an investigation or protective measures in response to the abuse allegations. Staff interviews indicated that management was informed of the incidents, but no substantial action was taken to address the behaviors or protect the victim. The facility's own policy defined such behaviors as abuse and required investigation and protection, but there was no evidence that these procedures were followed in this case.